Social needs of dual-enrolled Medicare-Medicaid patients with medication nonadherence in a telehealth medication therapy management program

BACKGROUND: Telehealth services that identify and address the social needs of patients can improve access to health care and social services. The social needs of medication therapy management (MTM)-eligible Medicare-Medicaid dual-enrolled patients are unknown. OBJECTIVE: To describe the social needs of Medicare-Medicaid dual-enrolled patients participating in a telephonic MTM program. METHODS: This study evaluated the findings of a social needs survey implemented within a telehealth MTM program. Surveys were offered telephonically to eligible Medicare-Medicaid patients of one insurance plan who were identified with medication nonadherence between July 13, 2020, and December 31, 2020. This study described patients who completed the survey during provision of a comprehensive medication review (CMR). Questions screened for social needs in the following social determinant of health domains: community and social context, economic stability, and neighborhood and physical environment. Descriptive statistics were used to describe results. RESULTS: Among 461 patients who completed CMRs, 358 completed the social needs survey. The most prevalent needs and concerns identified included lacking support to perform daily activities (165 [47%]), lacking companionship (81 [23%]), feeling left out (71 [20%]), feeling isolated (81 [23%]), not having enough money to pay bills (177 [49%]), worrying about running out of food (77 [22%]), or having run out of food within the last 12 months (81 [23%]). In this sample, 54 (15%) patients reported avoiding a provider visit because of transportation barriers. Certain individuals were without a steady place to live or were worried about losing their home (40 [11%]) and 35 (10%) reported struggling to keep a job. CONCLUSIONS: The identification of social needs among patient populations is necessary to reduce barriers to medication adherence and optimize health care utilization. This study described important social needs identified during the provision of a telehealth CMR among MTM-eligible Medicare-Medicaid dual-enrolled patients.


CONCLUSIONS:
The identification of social needs among patient populations is necessary to reduce barriers to medication

Plain language summary
This study described the findings from a social needs survey implemented in a medication therapy management (MTM) program among Medicare-Medicaid dual-enrolled patients. Key social needs identified among respondents were in the domains of community and social context (household support and loneliness), economic stability (income, employment, food insecurity, and housing insecurity), and neighborhood and physical environment (transportation and quality of housing).

Implications for managed care pharmacy
The results of this study support the need for greater implementation of social needs surveys and case management referrals within MTM programs. Adoption of the survey included in this study can be used by MTM programs and managed care organizations to support efforts to identify patients with social needs for optimal uptake of case management services designed to address social needs.
Social determinants of health (SDOH) are conditions in a person's life and environment that affect their health, ability to function, and quality of life. 1 SDOH reflect an individual's economic stability, educational opportunity, social and community context, health and health care quality, and their neighborhood environment. 1 When an individual experiences problems associated with these domains, they may be more likely to experience higher rates of preventable deaths when diagnosed with certain illnesses 2,3 and increased risk of specific chronic diseases, 4 medication nonadherence, 5 and health care utilization. [6][7][8] It is important to first identify SDOH-related needs, henceforth described as social needs, to connect patients to targeted services that can adequately address identified problems and improve their opportunity to engage with health care services, adopt healthy behaviors, and adhere to therapeutic regimens. As an example, a medically tailored meal program was found to significantly reduce health care utilization among individuals with specific chronic diseases with food insecurity when compared with a matched cohort. 9 Medicaid plan providers offer healthspecific services to low-income populations to address social needs likely to impact their overall health and healthy behaviors. These insurance providers leverage financial resources to provide case management services, housing support, peer services, and value-added services to address health care-related issues (ie, household cleaning to reduce asthma triggers). 10 Medicare Advantage plans also offer supplemental benefits that can address the social needs of their patient population. 11 Resolution of patient-specific social needs has the potential to improve medication adherence, improve health outcomes, and enhance quality of life. However, it is noteworthy that screening and referral programs in community and primary care settings have low uptake from targeted patient populations and, consequently, may have a limited effect overall on measured outcomes. 12 However, it should be noted, a subanalysis in one study found a telephonic social needs screening and navigation program in one health care system decreased health care utilization among their Medicaid-enrolled cohort. 13 Importantly, pharmacy services within primary care and community pharmacy settings, and offered at communitybased events, have begun to incorporate screenings for various social needs. 14 However, the impact of communitybased pharmacy programs may be limited by a lack of nearby available community resources or knowledge of community resources to address social needs. 15 Presently, there are limited data to describe the social needs of medication therapy management (MTM)-eligible Medicare-Medicaid dually enrolled patients. Medicare-Medicaid dual-enrolled patients 16 who are MTM eligible may be especially vulnerable to the effects of social needs given their reliance on a large number of medications, while also experiencing poverty sufficient to qualify for the Medicaid program. The objective of this study was to describe the social needs of dual-enrolled Medicare-Medicaid patients identified with medication nonadherence during a telehealth comprehensive medication review (CMR) in one MTM program.

Methods
This was a retrospective analysis of a social needs screening survey conducted in one telehealth MTM program. Participants received the survey as part of a routine CMR. Only patients who were identified with medication nonadherence were offered the social needs survey. The Ohio State University Institutional Review Board approved this study (protocol number: 2021H0231, approved July 28, 2021).

STUDY POPULATION
Patients included in this analysis responded to questions in the social needs survey instrument (Supplementary Exhibit 1, available in online article) between July 13, 2020, and December 31, 2020. Patients in this study were limited to participants within one health plan in California. Patients were included in this analysis if they were Medicare-Medicaid dual enrolled, eligible for MTM services, and aged 18 years or older and answered questions within the survey instrument. Patients who were offered the survey instrument but declined to answer any questions were omitted. MTM eligibility was determined based on the diagnosis of specific chronic conditions (≥3 of the following conditions: depression, diabetes, dyslipidemia, hepatitis C, heart failure, hypertension, osteoporosis, or a chronic respiratory condition), having 8 or more prescription medications for chronic conditions, and exceeding $4,255 in estimated annual medication costs.

MTM PROGRAM AND SOCIAL NEEDS SURVEY
The social needs survey was developed in collaboration with the Medicare-Medicaid plan provider to facilitate uptake of case management services designed to address social needs. This was done to ensure information collected adherence and optimize health care utilization. This study described important social needs identified during the provision of a telehealth CMR among MTM-eligible Medicare-Medicaid dual-enrolled patients.
of the CMR, the pharmacist also interviewed the patient to identify potential contributing factors for medication nonadherence. When possible, the pharmacist educated the patient and provided solutions to improve medication adherence. The patient was then offered solutions to improve medication adherence. In accordance with the medication action plan requirements of a CMR, a standardized summary of the medication review and patient interaction was mailed to the patient. The findings from the survey were recorded and transmitted electronically to the insurance plan to determine appropriateness for case management services.

STATISTICAL ANALYSIS
Data were coded and organized using Microsoft Excel (2016 MSO) and IBM SPSS software (v28.0, IBM Corp). Counts and percentages and means and SDs were calculated for categorical and continuous variables, respectively. Survey responses were reported as counts and percentages. Variables included in this analysis were age, sex, number of prescribers, number of pharmacies used by the patients, number of medications used to treat chronic conditions, and survey responses. The age, sex, number of prescription medications, and survey response were derived from data used for the CMR conducted between July 13, 2020, and December 31, 2020. The number of prescribers and number of pharmacies variables accounted for pharmacies and prescribers used in the 2020 calendar year (January 1, 2020, to December 31, 2020). The number of prescribers per patient was determined from a count of national provider identifiers of prescribers and the count of pharmacies from the National Council for Prescription Drug Programs identifier.

Results
There were 2,988 patients that were eligible for outreach during the evaluation period. A total of 461 patients were offered the survey in the study period. Included in this analysis were 358 MTM-eligible dual-enrolled Medicare-Medicaid patients who completed the survey. These patients were aged 68 (±9) years, predominantly female (227, 63%), and prescribed 11 (±2) medications. These patients used 7 (±4) prescribers and 2 (±1) pharmacies to obtain their medications during the year 2020. Complete information on characteristics can be found in Table 1.
Among 358 patients, 165 (46%), 81 (23%), 71 (20%), and 81 (23%) reported lacking support to perform daily activities, lacking companionship, feeling left out, and feeling isolated, respectively. A total of 177 (49%) patients reported not having enough money to pay bills. There were 77 (22%) and 81 (23%) patients who reported worrying about running out of food identified social needs that could be addressed by their social services and case management counselors.
Eligible patients were contacted by clinical pharmacists or student pharmacists within the MTM program to complete a CMR. Pharmacists used a call script and social needs survey (Supplementary Exhibit 1) to screen for social needs related to transportation, support/community, finance, housing, food, and loneliness. The survey instrument was developed using questions from the Social Needs Screening Tool published by the American Academy of Family Physicians Foundation 17 and a short survey that measured loneliness. 18 Pharmacists documented the findings of the survey reflective of the SDOH needs of patients. In the provision   Table 2.

Discussion
It has been estimated that only 10%-15% of preventable deaths could be reduced by improved access to health care and quality of health care within the United States. 19 In contrast, the risk factors associated with an individual's social needs were responsible for more than 80% of the variation in an individual's health outcomes. 20 Thus, federal programs within the United States such as Medicare Advantage and Medicaid have begun to offer services that identify and address an individual's social needs. 10, 11 The integration of screening and referral programs within an individual's insurance plan may facilitate patient navigation in the health care system. To our knowledge, this is the first study to describe a telehealth intervention designed to identify social needs outside of the community pharmacy or primary care setting. Essential social needs identified in this study included need for social support for daily activities, social isolation, economic instability, food and housing insecurity, problems with transportation, and poor quality of housing and utilities. The findings from this study suggested a social needs survey distributed via a telehealth program was effective in identifying social needs among patients. A benefit of these surveys and interventions conducted in partnership with an insurance plan was that these could be used to identify and target patients who benefit most from newly designed interventions and programs offered by health plans. 21 However, expansion of this type of service will require development of infrastructure within these organizations to improve data collection that can be effectively used to offer interventions that address the social needs of patients. 22 An additional benefit of a social needs surveys implemented at the insurance plan level is that patients could be identified and connected to relevant health care resources before social needs resulted in increased health care utilization.
Although this study importantly demonstrated that telehealth outreach was an effective means of identifying social needs, there are important areas to consider for future research. Future studies should evaluate the perceptions of pharmacists and their confidence in identifying and addressing social needs, if the inclusion of the survey significantly increased the length of an interaction with a patient, and if the survey should be offered to all MTM patients and not only when potential problems with medication adherence are identified. and ran out of food within the last 12 months, respectively. In this sample, 40 (11%) patients were without a steady place to live or worried they would lose their home, and 35 (10%) reported struggling to keep a job. Regarding home and quality of housing, among the cohort of patients that completed the survey, 34 (9%) reported problems with the quality of their housing including lack of heat, mold, pests, water leaks, lead in their pipes or paint, or smoke detectors, ovens, and stoves not working. Eleven (3%) patients reported having their utilities shut off or threatened to be shut off. Finally, 54 (15%) patients avoided visiting their  Additional important questions to address include determining if patient engagement with case management services and other innovative services offered by insurance plans would result in reduced health care utilization and increased medication adherence. This is especially important considering that 72% of our patients were aged 65 years or older, 100% were receiving 8 or more medications, 86% had 4 or more unique prescribers, and 70% were receiving medications from 2 or more pharmacies. It should be a high priority given the limited offering of social need interventions by insurance plans is driven by a limited budget and unclear return on investment. 11,22 It will also be necessary to assess the specific patient characteristics to influence an individual's likelihood of participation or success within such a program. This can inform if modification is needed to increase uptake of these interventions among eligible individuals.

LIMITATIONS
This study was limited to patients in one insurance plan provider and does not represent all dual-enrolled Medicare-Medicaid patients within the United States. Investigators were unable to assess the overall prevalence of social needs as the surveys were not a mandatory component of the MTM service. We were also unable to evaluate patient characteristics associated with specific social needs, which types of patients would benefit from targeting interventions, and if telephonic outreach was a barrier for completion of the survey. Furthermore, the data on the extent of patient engagement with the insurance case management service after referral were unavailable.

Conclusion
This study identified important social needs related to daily activities, loneliness, economic instability, food insecurity, and neighborhood and physical environment concerns among Medicare-Medicaid dual-enrolled patients. Important follow-up studies are needed to evaluate uptake of case management services and their effectiveness in reducing health care utilization and optimizing health outcomes in this population.

DISCLOSURES
Dr Nahata was supported in part by the Avatar Foundation. Dr Silva Almodóvar works as a research pharmacist within a medication management program, which provides medication therapy management services.